Runs of Anomalous Conduction

Report :

WPW syndrome

Atrial fibrillation

Runs of anomalous conduction (Wolff-Parkinson-White type ‘A’)

Borderline small voltage and T wave changes in frontal leads

Comment :

Syndrome, rather than mere conduction, because of the arrhythmia.

The patient is on sotalol and the ventricular rate is not as fast as usually seen in WPW atrial fibrillation. The anomalous complexes are too irregular for runs of VT ; some terminate quite long cycles at the beginning and the end of the recording. As usual in WPW, the conduction is mostly anomalous, with one or two completely normal QRSs separating the anomalous runs.

This is somewhat arbitrary, but the QRS looks more above than below the isoelectric line in V1 – hence the designation as type ‘A’. It is easy to remember left (‘A’) and right (‘B’) bypass using V1 : ‘A’ for above, ‘B’ for below, as defined by Rosenbaum in the year I was born, 1945102. This original division has been refined since; the important thing here is the clear-cut Rs morphology in lead V2, confirming the left-sided bypass in this case103.

This patient was admitted to CCU for elective cardioversion ; this was abandoned after no less than four unsuccessful attempts and he was sent home on increased dose of sotalol (60 mg BD) and enoxiparin. This blocked the Kent bundle quite well (116a).